Eosinophilic Esophagitis (EoE) - Twitter summary from #CSACI 2013 meeting

Diagnosis of Eosinophilic Esophagitis (EoE) dates back to 1995 with Kelly article in Gastroenterology.

Dr. Matt Greenhawt from Ann Arbor discussed the test-guided, targeted approach to dietary management for EoE. The Pro Con debate on eosinophilic esophagitis and what is the best dietary approach to treatment was with Dr Greenhawt vs Dr Kagalwalla. Dr. Greenhawt defended a tailored approach to EoE relying on prick and patch testing to determine dietary recommendations.

The goal of EoE therapy is true remission, with normal appearing esophagus, normal histology, absence of symptoms, and normal QOL.

Eosinophilic Esophagitis (click here to enlarge the image).

Dietary therapy

Dietary therapy has proven effective, addresses underlying mechanism of disease, and is a valid alternative to anti-inflammatory therapy (swallowed ICS). All 3 approaches to dietary change have been shown to work in EoE: elemental, tailored and empiric strategies.

Tailored dietary approach

A tailored dietary approach may minimize restrictions (depends on test results) and optimize QOL. A tailored approach to food avoidance in EoE prevents unnecessary avoidance and is probably the easiest to follow. In a study of 146 pediatric EoE patients who had SPT and APT, there was a 77% remission rate with tailored avoidance. A tailored dietary approach seems to perform better in children, there are poorer results in adults.

95% of allergists faced with EoE do prick testing. Food patch testing is done by about 40% of allergists. SPT and APT testing with 26 common food triggers may be required for tailored dietary management.

There is a limited role, and minimal data on serological testing for sIgE for foods in EoE. Both speakers agree on one thing: there is no role for IgE blood testing to determine dietary avoidance in Eosinophilic esophagitis.

Milk, egg, wheat, soy, and meats are the most common triggers, confirmed by elimination/reintroduction and repeat biopsies. A combination of SPT and APT results in high NPV, except for milk. Many patients will empirically avoid dairy in addition to those identified by testing. One recurring theme in Dr Greenhawt's talk was that cow's milk seems the biggest culprit overall for EoE.

8 foods cause 90% of food allergies (TEMPS WFS) (click to enlarge the image).

Empiric dietary restriction

Dr. Amir Kagalwalla (GI, not an allergist) from Chicago discussed the role of empiric dietary restriction for EoE. He defended the position of empiric dietary restriction and elemental diet in EoE. A 6 food elimination diet (SFED) and empiric diet may offer same results as a targeted restriction diet.

A hallmark study from 1995 (Kelly & Sampson) showed that foods responsible for EoE symptoms are discordant with SPT results. Several studies confirmed poor predictive values of SPT for identification of dietary triggers for EoE.

The elemental/amino acid based diet clearly effective in reducing symptoms and mucosal inflammation in EoE. Multiple studies show success with elemental diet (amino acid formula) in children. 97% of children clinically improved and 75% had histologic remission with SFED (milk, egg, wheat, soy, PN/TN, fish/SF). Several subsequent pediatric studies suggest consistent 70-75% response rate to SFED. A 4-food elimination diet (milk, egg, wheat, soy) may be 73% effective. Milk egg wheat and soy (especially milk and wheat) are repeatedly the main foods to avoid in EoE (4 food elimination diet).

Dr Kagalwalla has also published a one-food elimination for EoE: milk. It succeeded in 60% of cases.

A single-centre comparison of different dietary approaches (Henderson 2012) showed that elemental diet was better than SFED = modified SFED, better than tailored diet.

Atopy patch testing remains highly variable, there is no standard approach, it is dependant on the specific center.

There are typically more foods to worry about, more scopes, more visits, more costs with tailored vs. empiric dietary management.

Dr. Matt Greenhawt's rebuttal: we are unable to explain patch test variability, or obvious benefit to milk avoidance regardless of test results. The mean reduction in eosinophils with SFED was only to 13.6/hpf - this is NOT a remission (although in 74% of cases, eosinophils were reduced to fewer than 10 eos/hpf). Several negative studies only performed SPT, we cannot evaluate the effectiveness of tailored diet if APT is not performed. 6 weeks avoidance may not be sufficient, they will typically have to avoid foods for 12 weeks at Michigan University.

A 6 food elimination diet (SFED) actually requires restriction of more than 45 foods (different types of tree nuts, fish, shellfish).

Dr. Greenhawt confirmed: The 6 food elimination diet for EoE actually means avoiding up to 45 foods (multiple types of nuts/seafood).

A guide to successfully managing Eosinophilic Esophagitis in Q&A format from APFED http://goo.gl/0l9PX:

Twitter summary made possible by @IgECPD @allergydoc4kidz @DrAnneEllis

Three allergists did a great job posting updates from the 2013 meeting of the Canadian Society of Allergy and Clinical Immunology (#CSACI): @IgECPD @allergydoc4kidz @DrAnneEllis. Compared to year 2011, this represents 300% growth in Twitter use by the Canadian allergists (from one to three participants, stable since 2012.

For comparison, here are the tweets from the previous #CSACI meetings: http://allergynotes.blogspot.com/search/label/CSACI

Sign up for 2014 #AAAAI Twitter list and meeting of tweeting allergists in real life (tweetup)

The AAAAI has the advantage of a larger membership base compared to #CSACI and not surprisingly ten times more allergists (30) posted Twitter updates from the 2012 #AAAAI meeting. The AAAAI is now on Twitter at @AAAAI_org

This is a list of the allergists who are planning to use Twitter to post updates from the 2014 #AAAAI meeting. The list is open for edit, please feel free to add your own info.

The list shows the availability of the allergists by date and if they are planning to attend a tweetup (meeting of people who use Twitter or are following the tweets). See you at 2014 #AAAAI meeting in sunny San Diego!

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